(RN) Medical Reviewer II

BlueCross BlueShield of South Carolina - Florence, SC (30+ days ago)3.8


Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines.
Documents decisions using indicated protocol sets or clinical guidelines.
Provides support and review of medical claims and utilization practices.
Primary work location is Florence, SC, but may be located in Columbia, SC.
Work hours are Monday through Friday from 8 a.m. to 5 p.m.
Required Education
Associate degree in Nursing.
OR graduate of an accredited school of Nursing.
Required Work Experience
Two years of clinical experience.
Experience in Part B Medicare utilization review and MCS.
Clinical experience in specialty areas such as ER, PR, PACU, ICU or other critical area.
Required Skills and Abilities
Working knowledge of word processing software.
Ability to work independently, prioritize effectively and make sound decisions.
Good judgment skills.
Demonstrated customer service and organizational skills.
Demonstrated oral and written communication skills.
Analytical or critical-thinking skills.
Ability to handle confidential or sensitive information with discretion.
Microsoft Office skills.
Active RN licensure in state hired OR active compact multi-state RN license as defined by the Nurse Licensure Compact (NLC).